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Mental Health Advance Directives

Presented by Jenny Vaporetti

Mental Health Advocate

NAMI Keystone

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Participation ⬥ Planning ⬥ Peace of Mind

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Agenda

Introduction

Definition

Benefits

Providing Assistance

Provider’s Responsibility

Resources

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The Right to Choose

Individuals have the RIGHT to…

Receive Treatment

Consent to Treatment

Refuse Treatment

Except in an emergency

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Have Your Clients Ever…

Been forced to take medication they didn’t want?

Not been prescribed the medication they feel works best?

Worried about who would care for their children, pets, or home if they were in the hospital?

Had a support person they wanted to be involved in their care who was not permitted to be?

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What is a MHAD?

Mental Health Advance Directive (MHAD)

A written document of an individual’s preferred mental health treatment

Used when the individual lacks the capacity to make his/her own mental health treatment decisions

Natural part of the wellness plan

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Types of MHAD

Declaration Form

More defined, less flexible

Power of Attorney (POA) Form

More flexible, requires an agent

Combination

Declaration and POA Form
Allowed in Pennsylvania

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Types of MHAD

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Who Can Make a MHAD?

To make a MHAD your client…

Must be at least 18 years old or an emancipated minor

Currently needs to have capacity

Cannot have a legal guardian

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What is Capacity for a MHAD?

Capacity for a MHAD is only related to mental health treatment

Capacity is the basic ability to understand…

Your diagnosis
The risks and benefits of treatment
The risks and benefits of alternative treatments
The consequences of not having any treatment

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How is Capacity Determined?

It is assumed that a person has capacity

There must be two evaluations to determine a person does not have capacity

One by a psychiatrist and another by a mental health professional

Whenever possible, one of the evaluators will be the client’s treating professional

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What is an Agent?

MHAD Agent

The person the client has chosen in a MHAD to make his/her mental health decisions when he/she doesn’t have capacity

The client decides which powers the agent has

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What is an Agent?

An agent is someone who…

The client trusts to make the same decisions he/she would

Can make decisions based on discussions with the client and the MHAD

Is available to make treatment decisions

An agent is NOT someone who…

Is the client’s provider or an employee of his/her provider

Is an owner, operator, or employee of a residential facility the client resides (unless related)

Witnessed the MHAD or signed the MHAD for the client

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Types of MHAD Choices

Treatment

Consent or refusal for mental health treatment

A provider must comply if they can

Preferences

Includes choice of hospital, childcare, pet care, ect.

A provider is not legally bound to comply, but should respect them

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Types of MHAD Choices

Treatment

Medications
Electroconvulsive Therapy (ECT)
Drug Trials
Research Studies
Treatment History
Crisis Management
Dietary Needs (medically needed)

Preferences

Who should be called
Who will care for children or pets
Dietary Choices
Religious Choices
Preferred Hospital

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Written Consent

A person must specifically write his/her consent to…

Electroconvulsive Therapy (ECT)
Experimental Studies
Drug Trials

It is considered a refusal of treatment if there is no written consent

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Benefits

Having a MHAD gives your client…

More control over his/her treatment plan

Peace of mind that his/her preferences are known

Comfort in seeking treatment

Better treatment, faster

The ability to communicate his or her treatment preferences

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Benefits

When you assist your client in completing a MHAD it:

Improves the working alliance between your client and the providers

Creates a greater client satisfaction with mental health services

* MHAD is a billable service

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Client-Identified Barriers

Only 4% to 13% of outpatient clients have a completed MHAD

Studies suggest that 50% to 60% of clients with severe mental illness would complete an MHAD given the choice and necessary assistance

Client-Identified Barriers

Difficulty understanding a MHAD
Skepticism about the benefits of a MHAD
Lack of a trusted individual to serve as an agent
Complexity of filling out forms, obtaining witnesses, and making copies

(Swanson et al., 2006a as cited in Swanson et al., 2006b, p. 1944)

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Providing Assistance

A recent study showed that 61% of study participants (vs. 3% in control groups) completed an MHAD when provided with assistance that included:

An orientation to MHAD concepts
Review of past treatment experiences
Documentation of future treatment preferences with guided discussion of choices involved in planning for mental health care while incapacitated
Assistance with completion of forms, obtaining witnesses, and filing forms in the medical record

(Swanson et al., 2006b)

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Providing Assistance

Inform clients that they have a right to make treatment choices
Help clients determine which form meets their needs
Support client decision-making by asking questions and providing information
Encourage clients to include what treatments do work for them as well as treatments that have not worked
Make certain that the MHAD is valid: SIGNED and DATED in front of two witnesses who also signed the MHAD
Assist clients with making copies for providers, trusted family and friends
Assist clients to make a wallet card stating there is a MHAD and who to contact to get a copy

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Provider’s Responsibilities

Ask the client if he/she has a MHAD
Inform clients being discharged of a MHAD
Place copy of the MHAD in the mental health record for at least two years
Make any revocation or amendment of the MHAD part of the mental health record
Document any determination of capacity to make mental health care decisions
Comply with the MHAD (cannot violate clinical practice or medical standards)

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Provider’s Responsibilities

Inform clients and legal representative if the provider cannot comply with something in the MHAD (must document reasons)

Make reasonable efforts to transfer care if the provider cannot comply with the MHAD

Receive consent before providing treatment, unless there is an emergency

Cannot accept or refuse to accept an individual as a patient solely on the basis of having or not having a MHAD

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Conflict of Interest

Providers may find it difficult to support clients who make choices that differ from what the provider feels is best

A MHAD must reflect the client’s choices and preferences and never the provider’s

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Client Confidentiality

A copy of the MHAD should be provided to relevant treatment professionals in the event of a crisis

Presumably, your client wants the people treating him/her to have access to the MHAD

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MHAD Resources

NAMI: 412-366-3788
jvaporetti@namikeystonepa.org

Disability Rights PA

1-800-692-7443

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Thank You

This presentation was originally developed by Disability Rights Pittsburgh (DRNPA) and later adapted by NAMI Keystone Pennsylvania.

We appreciate the support and guidance we have received from DRNPA in our efforts to educate the community about MHADs.

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References

Swanson, J. W., Swartz, M.S., Ferron, J., Elbogen, E.B., & Van Dorn, R. (2006). Psychiatric advance directives among pubic mental health consumers in five U.S. cities: Prevalence, demand, and correlates. Journal of the American Academy of Psychiatry & Law, 34 43-57.

Swanson, J.W., Swartz, M.S., Elbogen, E.B., Van Dorn, R.A., Ferron, J., Wagner, H., et al. (2006). Facilitated psychiatric advance directives: A randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness. American Journal of Psychiatry, 163, 1943-1951

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Thank You!

Jenny Vaporetti

Mental Health Advocate

412-366-3788 (helpline)

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